Too much Tylenol

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Wednesday, Dec. 20, 2006
The FDA's Painkiller Warning: How to Avoid Taking Too Much
An overdose of Tylenol can damage the liver. The problem is, we're often taking it when we don't even realize it
By ALICE PARK

It's cold season, so you probably don't think anything of downing a dose or two of a cold medicine on top of the Tylenol you might be taking for that headache you got after muscling your way through the crowded shopping mall. Well, the Food and Drug Administration wants you to think twice about all that self-medicating you're doing with over-the-counter remedies. Every year, the agency says, about half of the deaths associated with taking pain killers containing acetominophen are due to unintended overdoses. Acetominophen, the primary ingredient in Tylenol, is also a common component of cold and flu remedies. The concern, says the FDA, is that people aren't aware of all the different compounds that contain acetominophen, so when they decide to boost their dose of Tylenol, or combine a pain killer with a cold caplet or two, they could be putting their liver in danger.

An overdose of acetominophen can damage the liver, which metabolizes and breaks down drugs. More than 200 million people take Tylenol in the U.S. each year, and about 200 a year die from liver failure when they accidentally take too much. What the FDA proposed is to require manufacturers of acetominophen-containing over-the-counter drugs to prominently note the presence of the compound, and warn people of the danger of liver toxicity when acetominophen is taken in excees of recommended doses.

According to Dr. Charles Cain, director of anesthesia at New York Presbyterian Hospital, it's not that hard to reach these danger levels. The average adult should not exceed 4g of acetominophen a day. If someone is taking two extra-strength tablets of Tylenol, which are 500 mg each, every four hours (instead of the recommended every six hours), and then adds a few doses of a cold medication during the day, then they're easily reaching about 4g-6g of acetominophen a day. Do that over a few days, says Cain, and you could damage your liver. Since most people are on several different types of medications already, the liver may be more vulnerable to danger when it's hit with an excess of acetominophen to process. And that's even before the glass of wine or bottle of beer that many of us like to have at the end of day; alcohol also puts the liver to work, and the combination of everything at once may be the perfect storm that sends the liver into failure.

The FDA warning is an effort to educate the public, says Cain, As the number of acetominophen-containing preparations becomes ubiquitous, the concern is that we are seeing instances where people are taking too much and wind up suffering from what should otherwise be a relatively safe medication.

At Columbia University Medical Center, doctors have been aware of the potential dangers of acetominophen overdose and for the past two months have provided patients with brochures indicating the daily amount of acetominophen their doctors recommend they take, and how much additional acetominophen they can safely take from other sources. Whenever I prescribe any medication, I always tell my patients that if they are buying drugs over the counter, to check for the label, and make sure that the medication does not contain any acetominophen, says Dr. Amit Sharma, an anesthesiologist at the hospital. If it does, then I tell them to cut down on the pain medication given by their doctor.

For the most part, Tylenol and acetominophen products are safe — that's why there are offered over-the-counter and without a doctor's prescription. But the FDA wants to alert people that like any drug, taking too much — more than your liver can handle — can be dangerous. And with more people taking more medications at a younger age, being aware of potential interactions among drugs, as well as potential overdoses, is critical. These over-the-counter drugs just have to be used with an eye toward the total dose per day, and amount being used over a period of days, says Cain. When used with care, acetominophen is extremely safe.

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A Common Misconception Proves Fatal

A grieving mother in Moore, Oklahoma, is determined that her Migraineur daughter's death teach others to take over-the-counter medications seriously and take them with care.

On June 24, 2003, 17-year-old Kellie Lynn McWilliams was suffering with pain from a Migraine attack and turned to Tylenol for pain relief. In pain and probably tired and groggy, Kellie took approximately 20 of the 500 mg acetaminophen capsules. That translates to ingesting 10 grams of acetaminophen; the maximum recommended within 24 hours is four grams.

When Kellie became ill, repeatedly vomiting, she was taken to the hospital. She told her mother, "I thought it was OK. It's just Tylenol, Ma." The side effects of the overdose caused kidney and liver damage resulting in organ failure, which caused her death on June 28.

According to Dr. Bill Banner, Medical Director of the Oklahoma Poison Control Center, an antidote is available, but it has to be administered within 18 hours of taking the acetaminophen.

The Managing Director of the Oklahoma Poison Control Center pointed out, "People think analgesics are safe, but they don't read the labels and they easily can make dosage errors ... fatal errors."

Kellie's mother, Jody McWilliams said, "If I can save one girl's life with her story ... that's all I want to do."

The American Association of Poison Control Centers shows the following statistics for reported acetaminophen poisonings in 2001:

• Total reported exposures: 57,516
• Reported exposures, under the age of 19: 40,774
• Unintentional overdoses: 35,705
• Intentional overdoses: 20,002
• Total treated for the exposure: 24,934
• Impact on health from the incident: none, 15,029; minor, 6,223; moderate, 3,138; major, 829; fatal: 120

We often discuss acetaminophen in relation to rebound headaches. This is another vital issue of which we must all be aware, not only with acetaminophen, but with all our medications. When we're in the midst of pain from a headache or Migraine, our thinking is not always clear. It can be difficult to keep track of how much of which medications we take and the times we take them. Here are some suggestions for avoiding problems:

• If someone is with you, put them in charge of your medications. Let them keep track of what you take at what time and be sure that you're not exceeding the recommended dosage.
• Wash and keep some small empty medication bottles. When you know you're getting a headache and Migraine, and are going to need medications, put the maximum amount you can take that day in the empty bottles. Then put the rest away where you will not accidentally pick it up and use it.
• Keep a notepad next to your medications and jot down the times you take medications, what you take, and how much.
• If the maximum dosage of medication doesn't give you relief, do NOT take more. Contact your doctor or go to the emergency room.

Always read the labels and heed the dosage instructions when taking medications. You don't want to say or hear, "I thought it was OK. It's just Tylenol, Ma."